Provider Demographics
NPI:1912966490
Name:GILLEMOT, PHILIP N (PA)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:N
Last Name:GILLEMOT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 1ST ST
Practice Address - Street 2:
Practice Address - City:WATKINS GLEN
Practice Address - State:NY
Practice Address - Zip Code:14891-1260
Practice Address - Country:US
Practice Address - Phone:607-535-2403
Practice Address - Fax:607-535-2537
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009351-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC8362OtherRR MEDICARE GROUP
NY02579793Medicaid
NYP00027394OtherRR MEDICARE PIN
NY02579793Medicaid
NYP00027394OtherRR MEDICARE PIN